Monday, February 08, 2010
Taking the pig out of the poke: Swine Flu and the public trust
by Quinn O'Neill
As the swine flu fiasco fades into the past, many people are breathing a sigh of relief; some because they were worried about getting sick, and some because they were sick of hearing about it. Since it all began, I’ve spent innumerable hours reading about the virus and vaccine. I read the peer-reviewed literature, newspaper articles, science blogs, magazine features, and vaccine package inserts. I read the unscientific stuff too; the conspiracy theories and the sensational reports of rare side effects.
I have come to a few conclusions. First of all, we can’t all make fully informed decisions about such issues. There is too much information and there are too many issues. Where do I stand on the issue of global warming? I hesitate to say; I spent all of my free time reading about the swine flu.
For many people, the quality of the information is as problematic as its quantity. The primary literature isn’t written in a way that is comprehensible for those who have no knowledge of medicine, statistics, and research design. The mainstream media conveys information in ways that are easier to understand, but the message ultimately depends on the source. Reports from the National Vaccine Information Center and the CDC in the United States, for example, would lead people to markedly different conclusions.
Perceptions of credibility are variable and subjective, and members of the public are ill-equipped to distinguish reliable evidence from sensationalism. For these reasons, it is crucial that the public be able to trust scientific authorities and government agencies to advise them appropriately. For a mass vaccination effort to be successful, people need to believe that authorities hold their health and safety as top priorities. Many people do not believe that this is the case. Their doubts may well be justified.
On various internet forums, ardent science defenders tossed insults and ridicule at the anti-vaccine crowd. They raved about the “overwhelming evidence” and “solid science” as if they have read all of it and judged it for themselves. The heart of the problem, however, is not the evidence or the quality of it, but the perceived lack of credibility of the authorities. In this respect, and this respect alone, I do sympathize with the anti-vaccine perspective. The authorities who are supposed to be ensuring our health and safety do not have a good track record.
There is a long list of chemicals that are currently on the market, which are known or suspected to cause cancer or other serious health problems. Bisphenol A and phthalates have been hard to miss in the news. The controversy surrounding aspartame seems to have gone away, but the many studies that suggested its carcinogenic potential have not. Perfluorooctanoic acid is a suspected carcinogen commonly found in non-stick pans. And hundreds of dangerous industrial chemicals have been detected in the umbilical cord blood of newborns.
Despite studies that suggest related health risks, these substances remain in widespread use. It would seem that when it comes to the safety of the products we consume, we have to be 100 percent sure, beyond any shadow of a doubt, that the product will kill us before we consider taking it off the market. This would suggest to me that financial considerations figure more prominently in the minds of policy and decision makers than does public health. Why should we continue to trust agencies that allowed the market to be flooded with products of questionable safety?
The wide ranging influence of industry is undeniable. Industry studies are significantly more likely to yield results and conclusions that favor industry products. They are also more likely to be published in high impact journals. For those of us who are willing and able to wade through the published literature and draw our own conclusions, it is becoming increasingly difficult to evaluate the evidence.
For any given product, the available studies usually yield mixed results. Some suggest that the product causes cancer, for example, while others fail to identify a link. It is important to note, however, that negative results and positive results don’t necessarily balance one another out. An effect is typically considered to be significant if it is large enough that we can be 95% sure that it couldn’t have occurred by chance alone. If we cannot be 95% sure, than we fail to find a significant effect. The substance may still be hazardous, but not to the extent that we can be really confident about it. It could also be hazardous in ways that weren’t investigated.
It follows from this, that a study demonstrating a significant risk is greater cause for concern than a negative study is cause for reassurance. The positive result implies that the drug is unsafe, but the negative result does not imply safety. Narrative reviews done by industry sometimes seem to forget this. They typically critique the positive studies, emphasize the negative ones, and conclude that the overwhelming evidence supports the safety and continued use of their product.
The available evidence may also be insufficient to definitively answer important questions. According to vaccine manufacturers’ package inserts, animal reproduction studies have not been conducted with H1N1 or seasonal flu vaccines. CSL elaborates, “It is also not known whether these vaccines can cause fetal harm when administered to a pregnant woman or can affect reproduction capacity.” If pregnant women were to be encouraged to get the vaccine, why were animal reproduction studies not done? If we don’t know whether these vaccines can cause fetal harm when administered to a pregnant woman, it would be prudent to find out.
Claims of vaccine-related miscarriages have been surfacing on the internet. The responses of vaccine defenders follow automatically and predictably. Temporal associations between the vaccine and miscarriages are attributed to coincidence. We are reminded that there is no evidence to suggest that flu vaccines can cause miscarriage. I agree that there is no evidence for such a link; but I think that we really ought to have looked. Potential to cause fetal harm should be investigated for any drug that is going to be widely used in pregnancy. Failure to do so is irresponsible. It cannot honestly be said that the benefits of a vaccine outweigh the risks if there are serious risks that are unknown. These are serious risks.
WHO coordinated a global effort among developed countries to donate vaccines to poorer countries. Superficially, this seemed like a really good idea. Let’s all pitch in and help supply developing countries with vaccines to save lives. The fact is, however, that more people died from hunger every day in developing countries than from H1N1 all year. Why did WHO advocate expensive vaccinations for people who were many times more likely to starve to death? If world public health is their number one priority, their actions are inexplicable.
Science and technology is only as noble as the purposes for which it is used. Evidently, it can be used to generate profit and to improve our lives. It can also expose us to health hazards and create new problems. Science and technology brought us industrial chemicals that now pollute the environment and threaten wildlife. It brought us effective antibiotics, antidepressants, and pain medications that are now detectable in our drinking water. It may be making our lives healthier and easier in the present, at the expense of future generations.
Blind faith in anything is dangerous, but perhaps especially so with science and technology. Medical professionals and lay people alike were primed to dismiss claims of vaccine side effects. Refusal to consider the possibility of a causal link is problematic when it leads to underreporting of adverse events. Physicians’ unwillingness to report such cases was a common complaint among those claiming serious side effects. While it is entirely possible that these incidents were unrelated to the vaccine, it is unacceptable for physicians to decline to report the incidents.
While I don't deny that the anti-vaccine movement may cause serious harm, knee jerk reactions and indiscriminate slinging of ridicule and insults seems to be more popular among the pro-vaccine camp. This too can be dangerous. It may have the effect of silencing those who distrust science without alleviating their fears. More importantly, it may stifle valid criticisms. On several occasions, the mere suggestion that we should conduct animal reproductive studies earned me the label of ‘anti-vax wingnut’. It also elicited statements about polio and pertussis vaccines and the alleged mercury-autism connection. Many members of the pro-vaccine camp seem to think that all vaccines and all applications of vaccines are the same. If one is safe or appropriate, then they all must be. Any criticism of any aspect of a vaccine merits the same response.
As we move further into what Bill Gates has called “the decade of vaccines”, the automatic dismissal of all vaccine criticisms becomes increasingly hazardous. Childhood vaccination is at an all time high and the vaccine industry is still growing. We routinely vaccinate livestock, fish, and pets, and we are exploring the potential for new vaccine uses. Each use of each vaccine must be considered separately. The safety and efficacy of a pertussis vaccine will tell us nothing about the safety and appropriateness of a new vaccine developed to reduce methane emissions from livestock.
Expressing any criticism of vaccines, science, or government agencies now carries a serious risk to one’s reputation. Wolfgang Wodarg, an ignorant, self-aggrandizing, flaming asshole, according to epidemiologists of the science blog, “Effect Measure”, put his reputation on the line when he called for an inquiry into WHO’s management of the swine flu.
In my opinion, the inquiry is an excellent idea. If WHO is exonerated, its damaged credibility should be somewhat restored. Similarly, if inappropriate ties to vaccine manufacturers are identified and steps are taken to remedy the situation, the image of the agency should improve. Assurances from authorities whose own credibility has been questioned do little to quell public suspicion and distrust. I respect Wodarg for having the integrity to take this personal risk.
Now is a bad time for scientific authorities and government agencies to lose the trust of the public. The human population is growing at an alarming rate and the availability of essential resources is declining. The environment is becoming progressively less habitable to our own species and to many others. A variety of health conditions are on the rise: cancer, diabetes, asthma, and autism. Science offers the best chance of finding real solutions to these problems. Government agencies need to be trustworthy; and we need to have the integrity to challenge them when there is doubt.
Posted by Quinn O'Neill at 09:05 AM | Permalink